s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DEPARTMENT OF HEALTH AND HUMAN SERVICESForm ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICESOMB No. 0938-0266THE PEOPLE OF THE STATE OF NEW YORK TOAMBULATORY SURGICAL CENTER SURVEYMEDICARE SUPPLIER NUMBERFACILITY NAME AND ADDRESS (City, State, Zip Code)GREETINGS:NAME OF SURVEYOR AND PROFESSIONAL TITLEWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofSURVEYORS PROFESSIONAL TITLE1. Initial SurveyResurvey2.LIST ADDITIONAL SURVEYORS NAMESTITLESYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorable, 20 County,day ofSURVEY TEAM COMPOSITION(Attorney must sign above and type name below)Indicate the Number of Surveyors According to Discipline:Life Safety CodeH.A. B.C.D.E.I.J.K.L.M.Attorney(s) forRecordsSocialF.National Institute of MentalQualified Mental RetardationG.N.Office and P.O. AddressNOTE: More than one discipline may be marked for surveyors qualified in multiple disciplines.Telephone No.: Facsimile No.: E-Mail Address:Indicate the Total Number of Surveyors Onsite: Q1Form CMS-378 (01/97)Mobile Tel. No.:Page 1American LegalNet, Inc. www.USCourtForms.coms): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name of FacilityTHE PEOPLE OF THE STATE OF NEW YORK TONO METCODEEXPLANATORY STATEMENTSMETN/AQ2§416.40 Condition For Coverage: Compliance With StateLicensure Law. The ASC must comply with state licensure requirements.Q3§416.41 ConditIon For Coverage: Governing Body andGREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofManagement The ASC must have a governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the ASCs total operation and for ensuring that these policies are administered so as to provide quality health care in a safe environment. When services are provided through a contract with an outside resource, the ASC must assure that these services are provided in a safe and effective manner.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Q4(a) Standard: Hospitalization. The ASC must have an effective procedure for the immediate transfer to a hospital, of patients requiring emergency medical care beyond the capabilities of the ASC. This hospital must be a local, Medicare participating hospital or a local, non-participating hospital that meets the requirements for payment for emergency services under §482.2 of this chapter. The ASC must have a written transfer agreement with such a hospital, or all physicians performing surgery in the ASC must have admitting privileges at such a hospital., one of the Justices of theCourt in Witness, Honorable, 20 County,day of(Attorney must sign above and type name below)Q5§416.42 ConditIon for Coverage: Surgical Services.Attorney(s) forSurgical procedures must be performed in a safe manner by qualified physicians who have been granted clinical privileges by the governing body of the ASC in accordance with approved policies and procedures of the ASC.Q6(a) Standard: Anesthetic rIsk and evaluation. A physcian must examine the patient immediately before surgery to evaluate the risk of anesthesia and of the procedure to be performed. Before discharge from the ASC, each patient must be evaluated by a physician for proper anesthesia recovery.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:PageForm CMS-378 (01/97)American LegalNet, Inc. www.USCourtForms.coms): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name of FacilityTHE PEOPLE OF THE STATE OF NEW YORK TONO METCODEEXPLANATORY STATEMENTSMETN/AQ7(b) Standard: Administration of anesthesia.Anesthetics must be administered by only (1) A qualified anesthesiologist; or (2) A physician qualified to administer anesthesia, aGREETINGS:certified registered nurse anesthetist, a supervised trainee in an approved educational program or an anesthesia assistant as defined in §410.68(b). In those cases where a nonphysician administers the anesthesia, the anesthetist must be under the supervision of the operating physician, and in the caseWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofof anesthesiologists assistant, under thesupervision of an anesthesiologist.Q8(c) Standard: Discharge.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.All patients are discharged in the company of a responsible adult, except those exempted by the attending physician.Q9§416.43 ConditIon for Coverage: Evaluation of Quality. The ASC, with the active participation of the medical staff, must conduct an ongoing, comprehensive self-assessment of the quality of care provided, including medical necessity of procedures performed and appropriateness of care, and use findings, when appropriate, in the revision of center policies and consideration of clinical privileges., one of the Justices of theCourt in Witness, Honorable, 20 County,day of(Attorney must sign above and type name below)Q10§416